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UNRGROUND TANK OFFICIAL INSPECTION PORT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />COUNTY NAME Mailing Address: P.O. Box 388 <br />Stockton, CA 95201-0388 <br />468-3420 COUNTY # 32 <br />SITE NAME: INSPECTION DATE: <br />P)cl <br />SITE ADDRESS: <br />dl)1CITY/STATE/ZIP <br />—A- Dj. /0— Ll A -& <br />CHANGES SITE /OWNER/PERMIYES I <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TANK <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TANK <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TANK <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />11?9 if <br />OPERATIONAL TANK 5619715/ <br />PERMIT TO OPERATE <br />TANK C NTENTS <br />50 <br />FLAMMABLE VAPORS REMOVED 40 <br />MAJOR MINOR <br />1 2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 4 <br />ACCESS LOCATIONS SEALED 41 42 <br />53 <br />54 <br />APPROVED CONSTRUCTION <br />55 <br />56 <br />OWNER/OPERATOR MONITORING 44 45 <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />APPROVED MONITORING SYSTEM <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS: <br />SYSTEM STATUS (MUST MARK ONE) <br />7 8 <br />9 10 <br />MONITORING SYSTEM <br />APPROVED MONITOR FREQUENCY <br />65 <br />---------- <br />11 12 <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />PIPING <br />17 18 <br />19 20 <br />INVENTORY RECONCILIATION <br />TANK GAUGING <br />-------- <br />- <br />21 22 <br />23 24 <br />APPROVED RESPONSE PLAN <br />25 26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 28 <br />ry <br />SAMPLING <br />29 30 <br />APPROVED TANK REPAIRS <br />31 32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />SAFETY HAZARD <br />35 36 <br />CONDITIONS ABATED <br />37 <br />-- ------ ---- <br />TEMPORARY TANK CLOSURE <br />46 <br />147 <br />_R <br />PIPING <br />48 <br />:49 <br />REMOVAL OF RESIDUAL 38 139 <br />50 <br />FLAMMABLE VAPORS REMOVED 40 <br />51 <br />52 <br />ACCESS LOCATIONS SEALED 41 42 <br />53 <br />54 <br />POWER DISCONNECTED 43 <br />55 <br />56 <br />OWNER/OPERATOR MONITORING 44 45 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS: <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />147 <br />_R <br />PIPING <br />48 <br />:49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS: <br />SYSTEM STATUS (MUST MARK ONE) <br />57 58 <br />MAJOR, MINORE] Z <br />VIOL. VIOL. VOL. <br />59 <br />OFFICE: INSP*:4 -�,, t 6L— <br />TITLE: <br />4 FE—h <br />HUT -3 WNte - Original Yellow - Owner's Copy Pink - File Coov <br />viW9]r*.m <br />BE <br />BECK: <br />